Failure to Conduct and Document Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the drug regimen of a resident was reviewed by a consultant pharmacist as required. Specifically, the consultant pharmacist reports from July and October 2024 did not include Resident 13, indicating that her medication regimen was not reviewed during these months. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the absence of a report for Resident 13 for the specified months. Additionally, there was no documentation in Resident 13's clinical record to indicate that any irregularities were identified or reported to her attending physician. Consequently, there was no evidence that the attending physician reviewed any potential irregularities or documented any actions taken in response. This lack of documentation and communication represents a failure to comply with the regulatory requirements for drug regimen review and reporting.
Plan Of Correction
1. The facility cannot retroactively correct deficient practice. 2. The DON/designee will do a 30 day look back to ensure pharmacy consultant reviews requiring recommendations are reviewed by MD and are followed up on. The facility's Medical Records Coordinator or designee will maintain a log of pharmacist reports, ensuring all residents are listed in each month's review. The attending physician receives and reviews all recommendations. Documentation of physician action is entered into the resident's chart. 3. The NHA will educate Director of Nursing (DON) on: - Verifying that all consultant pharmacist recommendations are received, reviewed, and acted upon by the physician. - Ensuring documentation of physician response is entered into the medical record. 4. The DON or designee will audit monthly pharmacy reviews to ensure recommendations are followed up and completed by a physician and are then placed in the resident records each month. The QAPI team will review pharmacy audits monthly to assess ongoing monitoring.